STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Case No. 2006000924 and 2006000925 Ol-\5U44 MONTICELLO PARTNERSHIP, LTD., A/K/A JEFFERSON NURSING CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”) by and through the undersigned counsel, and files this Administrative Complaint against MONTICELLO PARTNERSHIP, LTD., A/K/A JEFFERSON NURSING CENTER (“Respondent”), a skilled nursing facility, pursuant to Chapter 400, Part II, and Sections 120.569 and 120.57, Florida Statutes, . NATURE OF THE ACTION 1, This is an action to impose an administrative fine in the amount of $10,000 pursuant to Section 400.23(8) and (8)(a), Florida Statutes. 2. This is an action to impose a 6-month survey cycle fee pursuant to Section 400.19(3) in the amount of $6,000. 3. This is an action to impose a conditional license pursuant to Section 400.23(7)(b), Florida Statutes. Page 1 of 9 JURISDICTION AND VENUE 4. This tribunal has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 5. Venue shall be determined pursuant to Section 400.121 Florida Statutes and Rule 28-106.207, Florida Administrative Code. PARTIES 6. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes, and Rule 59A-4, Florida Administrative Code. 7. Respondent, is a 60-bed skilled nursing facility located at 1780 North Jefferson Street, Monticello, Florida 32344. At all times material hereto, Respondent has been a facility licensed under and required to comply with, Chapter 400, Part IT, Florida Statutes and Chapter 59A-4, Florida Administrative Code, having been issued license number 1257096. COUNT I CLASS I VIOLATION WARRANTING AN ADMINISTRATIVE FINE SECTION 400.23, FLORIDA STATUTES SECTION 400.102, FLORIDA STATUTES 8. AHCA realleges and incorporates Paragraphs 1 through 7 above as if fully set forth herein, 9. Section 400.23, Florida Statutes, states in pertinent part: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. ... The agency shall indicate the classification on the face of the notice of deficiencies as follows: Page 2 of 9 (a) A class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class Il deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency, 10. Section 400,102, Florida Statutes, states in pertinent part: (1) Any of the following conditions shall be grounds for action by the agency against a licensee: (a) An intentional or negligent act materially affecting the health or safety of residents of the facility; 11. On December 12-14, 2005, AHCA conducted a survey at Respondent’s facility. At that time, based on observation, staff interviews and resident interviews, it was determined that Respondent failed to protect a resident from environmental conditions materially affecting the resident's health. Specifically, Respondent permitted a totally dependent resident to be subjected to noxious paint fumes which caused the resident respiratory distress, gasping for air, and crying, as set forth in more detail in the survey report, the relevant portion of which is incorporated herein and attached hereto as Exhibit A. 12. The aforesaid failure by Respondent constitutes an isolated Class I violation. 13. Respondent has been notified of its violation and advised that it has created immediate jeopardy for said resident. Respondent has also been assessed a fine in the amount of $10,000. Page 3 of 9 COUNT If VIOLATION WARRANTING 6-MONTH SURVEY CYCLE FEE SECTION 400.19 14. AHCA realleges and reincorporates Paragraphs 1 through 13 above as if set forth fully herein. 15. Section 400.19 provides in pertinent part: (3) The agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been cited for two or more class II deficiencies arising from separate surveys or investigations within _ a 60-day period, or has had three or more substantiated complaints within a 6- month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. ... 16. As a result of the foregoing Class I violation, AHCA has assessed a 6- month survey cycle fee in the amount of $6,000 against Respondent. COUNT UT VIOLATION WARRANTING CONDITIONAL LICENSURE SECTION 400.23(7)(b) 17. AHCA realleges and reincorporates Paragraphs 1 through 16 above as if set forth fully herein. 18. Section 400.23, Florida Statutes, states in relevant part: (7) The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home. * * * Page 4 of 9 19. (b) A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class II deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class I, class II, or class I deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. AHCA has assigned a conditional licensure status to Respondent based upon the determination that the facility was not in substantial compliance with applicable laws and rules during the December 12-14, 2005 survey, due to Respondent’s Class I violation described above. The effective date of the conditional license is December 14, 2005. Subsequent thereto, AHCA determined that Respondent was in compliance, and Respondent’s standard licensure has been restored, effective February 3, 2006. A copy of the conditional license for the period December 14, 2005, through December 31, 2005, is attached hereto and made a part hereof as Exhibit B-1. A copy of the conditional license for the period beginning on January 1, 2006, is attached hereto and made a part hereof as Exhibit B-2, A copy of the standard license effective February 3, 2006, is attached hereto and made a part hereof as Exhibit C. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1. Make factual and legal findings in favor of AHCA as to the allegations contained in Counts I, II and III hereof. Uphold the administrative fine assessed in the amount of $10,000 for the isolated Class I violation found during the December 12-14, 2005 survey. Uphold the 6-month cycle survey fee in the amount of $6,000. Uphold the issuance of the conditional license. Page 5 of 9 5. Such other relief as this tribunal may deem appropriate, including the assessment of costs related to the investigation and prosecution of this case, if applicable. DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Respondent shall post its most current license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk, RESPONDENT IS FURTHER NOTIFIED THAT IF THE REQUEST FOR HEARING JIS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, THE ALLEGATIONS IN THIS Page 6 of 9 ADMINISTRATIVE COMPLAINT WILL BE DEEMED ADMITTED AND A FINAL ORDER WILL BE ENTERED. Submitted on this 4 May of ™ hve Dy 2006. Karin M. Byrne, Esq. Assistant General Counsel Fla. Bar No.356255 Agency for Health Care Administration 2727 Mahan Drive, Bldg. #3, MSC #3 Tallahassee, FL 32308 Phone: (850) 922-5873 Fax: (850) 921-0158 or (850) 413-9313 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original Administrative Complaint and Election of Rights form has been sent by U.S. Certified Mail, Return Receipt Requested (receipt #7003 1010 0000 9716 1578) to MONTICELLO PARTNERSHIP, LTD., A/K/A JEFFERSON NURSING CENTER, ATTN: Administrator, 1780 N. Jefferson Street, Monticello, Florida 32344 and Return Receipt Requested (receipt # 7003 1010 0000 9716 1585) to Bittman, Michael J., 301 E. Pine Street, Suite 1400, Orlando, Florida 32801. DATED this J9™ day of Wicuve th 2006. aa (3 & aM By Bye E 2s —_ Agency for Health ‘Care Administration Page 7 of 9 Cc ¢ PRINTED: 01/2 //2005 ' sae . ‘ FORM APPROVED Agency for Health Care Administration (x1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING B, WING STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION 23301 12/14/2005 STREET ADDRESS, CITY, STATE, ZIP CODE 1780 N JEFFERSON STREET MONTICELLO, FL 32344 NAME OF PROVIDER OR SUPPLIER JEFFERSON NURSING CENTER (x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES i 1D | PROVIDER'S PLAN OF CORRECTION (x5) PREFIX {EACH DEFICIENCY MUST BE PRECEEDED BY FULL : PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAR REGULATORY OR LSC IDENTIFYING INFORMATION) 1 TAG | CROSS-REFERENCED TO THE APPROPRIATE DATE - . i DEFICIENCY) N216| 400.102(1)(a) Health and Safety of Resident 400.102(1)(a) grounds for action by the agency against a licensee; (a) An intentional or negli Agency for Health Care Administration STATE FORM (1) Any of the following conditions shall be | i | gent act materially 699 spSS11 ifcontinuation sheet 12 of 16 EXHIBIT A Y) Agence for Health Care Administration (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION A. BUILDING 23301 NAME OF PROVIDER OR SUPPLIER JEFFERSON NURSING CENTER MONTICELLO, FL 32344 SUMMARY STATEMENT OF DEFICIENCIES ‘X4) ID oe H DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX | PREFIX (EAC TAG REGULATORY OR LSC IDENTIFYING INFORMATION) N 216] Continued From page 12 affecting the health or safety of residents of the : facility. This Rule is not met as evidenced by: Based on observation, interview and record the facility failed to protect 1 of 31 sampled residents (#8) from noxious paint fumes resulting in respiratory distress, gasping for air and crying. Findings include: Record review of resident #8's clinical chart reveals resident #8 is on Hospice care with a diagnosis of CHF (congestive heart failure), bilateral below the knee amputations, diabetes, stroke, hypertension and ischemic heart disease. ; Resident #8 routinely uses oxygen via nasal cannula at 2-3 liters per minute to sustain oxygen saturation levels within normal limits of 92-100%. Observations made on 12/12/05 at approximately | 2:55 p.m. revealed resident #8 in his/herroom =| with the door closed. The maintenance man was i painting in resident #8's room. The door was closed, all windows were closed, the heating/air conditioning unit was off, no fans or vents were in use and the room was completely odored with | paint fumes. Resident #8 was noted to have very laborious breathing, to be gasping for air and had audible gurgles and rales. Resident #8 was not receiving any oxygen as the concentrator was off ; and the nasal canula out of the nares. This surveyor then left the room and summoned another surveyor to confirm the findings. At approximately 2:57 p.m. on 12/12/05 this surveyor and another surveyor reentered the closed room of resident #8 to observe the same findings as earlier mentioned. Resident #8 had very labored breathing, was gasping for air, had | Agency for Health Care Administration STATE FORM bens SDSS11 STREET ADDRESS, CITY, STATE, ZIP CODE 1780 N JEFFERSON STREET (X2) MULTIPLE CONSTRUCTION B. WING DEFICIENCY) PROVIDER'S PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG | CROSS-REFERENCED TO THE APPROPRIATE DATE PRINTED: 01/27/2006 FORM APPROVED (X3) DATE SURVEY COMPLETED 12/14/2005 If continuation sheet 13 of 16 Agence for Health Gare Administration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION {X%4) ID PREFIX TAG N 216 Agency for Health Care Administration NAME OF PROVIDER OR SUPPLIER JEFFERSON NURSING CENTER C ») {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 23301 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 13 audible gurgles and rales and had no oxygen in place.’ The maintenance man continued to paint , in resident #8's room without any ventilation. : At approximately 3:12 p.m., this surveyor ! informed the Director of Nursing (DON) of the | above findings. The DON confirmed the room =| was full of paint fumes and that resident #8 was having difficulty breathing. The DON checked resident #8's oxygen saturation levels which fluctuated between 85-92% (normal range 92-100%.) The DON then moved resident #8 out of the room with the paint fumes and placed | resident #8 into the hallway. Resident #8 was noted by this writer and another surveyor to have tears streaming down his/her face during this | time period (it is noted on the MDS-minimum data set dated 10/13/05 that resident #8 does not speak.) Once in the hallway, resident #8's oxygen saturation levels were rechecked at approximately 3:20 p.m., the findings were 82-88% (very low.) Resident #8 was then moved | into a room on another hall at approximately 3:35 p.m. Itis noted that oxygen was never applied to | resident #8 during the entire above mentioned incident until resident #8 was placed in the \ second room at approximately 3:35 p.m., 40 | minutes after resident #8 was observed wheezing and gasping for breath and 23 minutes after oxygen saturation levels were significantly low at 85%. 1 Record review of resident #8's MDS dated 10/13/05 reveals the fallowing: cognition 3 (severely impaired), speech clarity 2 (no speech), transfer 4/2 (total dependence on staff with one | person physical assist), mode of transfer (mechanical lift), special treatments (oxygen therapy.) Thus resident #8 could not get out of the room without assistance and could not speak to inform anyone the need to be removed from @Bg9 STATE FORM (X2) MULTIPLE CONSTRUCTION A, BUILDING B, WING STREET ADDRESS, CITY, STATE, ZIP CODE 1780 N JEFFERSON STREET MONTICELLO, FL 32344 SDSS11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) PRINTED: 01/27/2006 FORM APPROVED (%3) DATE SURVEY COMPLETED 12/14/2005 (x5) COMPLETE DATE if continuation sheet 14 of 16 ( C PRINTED: 01/27/2006 _ FORM APPROVED istration Agency for Health Care Admi STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING B. WING __—— (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 23301 12/14/2005 STREET ADDRESS, CITY, STATE, ZIP CODE 1780 N JEFFERSON STREET MONTICELLO, FL 32344 NAME OF PROVIDER OR SUPPLIER JEFFERSON NURSING CENTER (x4) ID | SUMMARY STATEMENT OF DEFICIENCIES a) PROVIDER'S PLAN OF CORRECTION (KE) eeex | (EACH DEFICIENCY MUST BE PRECEEDED BY FULL 1 PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | "yaG | GROSS-REFERENCED TO THE APPROPRIATE DATE ; DEFICIENCY) Continued From page 14 the room. An interview with the maintenance man was ‘| conducted on 42/12/05 at approximately 4:30 | p.m. During this interview the maintenance man was asked if there was a policy and/or procedure for painting room with residents. The i maintenance man stated "no ma'am, | don't believe i do." He then stated "when | paint a resident's room and the paint fumes are too strong the resident just gets up and leaves." He then stated "I used poor judgement, but the CNA's (certified nursing assistants) came in and out of the room and they did not tell me the paint fumes were too strong." i Record review of the initial Hospice assessment form dated 10/3/05 states resident #8 receives oxygen at 2 liters per minute via nasal cannula as needed. Per interview with the DON 12/4 2/05 and per new policy and procedure provided 12/14/05, prn (as needed) oxygen use Means "when oxygen saturation levels are below 92%.) i Record review of nursing notes from 12/12/05 i events are as follows: 42/12/05, 3:00 p.m.: "Summoned to room by AHCA surveyor. Resident #8 in bed breathing heavily. Audible gurgles noted. Room with paint fumes. Oxygen sats at 85%, fluctuating to92% | and back to 85%. Resident removed from room, ! placed in hallway. " Itis noted the most recent nursing note prior to 42/12/05 was on 11/20/05 and it stated "oxygen sats fluctuating between 89-96% on room air, i oxygen at 2 liters per minute. Hospice nursing notes documented some dyspnea on 41/30/05 and use of oxygen at 2.5 Agency for Health Care Administration STATE FORM 5899 spDSsstt If continuation sheet 15 of 16 ( , C PRINTED: 01/27/2008 FORM APPROVED ministration Agene for Health Care Ad STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A, BUILDING 8. WING (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 23304 412144/2005 STREET ADDRESS, CITY, STATE, ZIP CODE 4780 N JEFFERSON STREET MONTICELLO, FL 32344 NAME OF PROVIDER OR SUPPLIER JEFFERSON NURSING CENTER PROVIDER'S PLAN OF CORRECTION (x5) (x4) ID SUMMARY STATEMENT OF DEFICIENCIES : ID : PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG. GROSS-REFERENCED TO THE APPROPRIATE DATE ( ' DEFICIENCY) Continued From page 15 liters per minute. Review of label attached to the paint can used in resident #8's room read “USE WITH ADEQUATE VENTILATION," “if inhaled, remove to fresh air. If breathing is difficult, get medical attention immediately." Review of the MSDS (material safety data sheet) of the paint states "vapor may be harmful if inhaled.” "Where ventilation is inadequate, use a | NIOSH-approved air purifying respirator with the appropriate chemical cartridges or positive-pressure, air supplied respirator." Based on these findings the facility neglected to protect resident #8 who is a bilateral below the == | knee amputee with known congestive heart : failure that uses oxygen and is on Hospice from physical and mental anguish while painting his/her room without adequate ventilation. Immediate jeopardy was identified on 12/12/05 and removed on 12/13/05 Class I/Jeopardy | Isolated Correction Date: Immediate Agency for Health Care Administration STATE FORM 6809 spSss11 if continuation sheet 16 of 16 MEIN ISS CERTIFICATE #: 13237 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE SKILLED NURSING FACILITY CONDITIONAL This is to confirm that MONTICELLO PARTNERSHIP LTD. has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part IL, Florida Statutes, and as the licensee is authorized ‘ to operate the following: JEFFERSON NURSING CENTER 1780 N. JEFFERSON ST MONTICELLO, FL 32344 TOTAL: 60 BEDS STATUS CHANGE ACTION EFFECTIVE DATE: 12/14/2005 LICENSE EXPIRATION DATE: 12/31/2005 , Division of Health Quality Assurance EXHIBIT _©- 1. LICENSE #: SNF1257096 fillies Neil State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE SKILLED NURSING FACILITY CONDITIONAL (eh Fe sitititt ii This is to confirm that MONTICELLO PARTNERSHIP LTD. has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: JEFFERSON NURSING CENTER 1780 N. JEFFERSON ST MONTICELLO, FL 32344 TOTAL: 60 BEDS RENEWAL ACTION EFFECTIVE DATE: 01/01/2006 LICENSE EXPIRATION DATE: 12/31/2006 EXHIBIT _B-2 LICENSE #: SNF1257096 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE SKILLED NURSING FACILITY STANDARD This is to confirm that MONTICELLO PARTNERSHIP LTD. has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized : to operate the following: JEFFERSON NURSING CENTER 1780 N. JEFFERSON ST MONTICELLO, FL 32344 TOTAL: 60 BEDS STATUS CHANGE ACTION EFFECTIVE DATE: 02/03/2006 LICENSE EXPIRATION DATE: 12/31/2006 EXHIBIT My Hh iz ey i STRATIVE Postaga | Cantiied Fea Hetum Reclept Fee (Endorsement Required) Rastricted Dolivery Fee (Endorsement Required) Total Postage 7003 1010 oo00 Vib 158s No, or PO Bax No, SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, and 3, Also complete Item 4 if Restricted Delivery Is desired. ™ Print your name and address on the reverse So that we can return the card to you, ® Attach this card to the back of the mailplece, or on the front if space permits, Michael J, Bittman 301 E, Pine Street, Suite 1400 Orlando, Florida 32801 1. Article Addressed to: Michael J. Bittman 301 E. Pine Street, Suite 1400 HEARINGS Postmark Hera BSD Doe 34Y AY OCR TST COMPLETE THIS SECTION ON DELIVERY . Oe by (Please G. Glearly) |B, Date of Delivery C. Signature : a 0 Agent ‘) fe. A Adjtrassee x L t O Ag D. Is delivery address different from item EP [ IFYES, anjer dellyery address betow: - CO) No C , . a x Colk Sas Orlando, Florida 32801 3. Service Type Certified Mail (1) Express Mail { C Registered Return Recelpt for Merchandise O insured Mal =O G.0.p, 4, Restricted Delivery? (Extra Fee) 0 Yes 2. Article $5 PS Fortr 195-00-M-0952 i J Cenified Fea Ratum Aeclept Fea (Endorsement Required) Restricted Delivary Fae (Endorsement Required) Total Postage &~ Sant Ta 7003 1010 0000 W?ib 1576 Giiy, State, ZIP PS Form a0, 1a SENDER: COMPLETE THIS SECTION = Complete items 1, 2, and 3. Also complete ~item 4 if Restricted Delivery is desired. ® Print your name and address on the reverse so that we can return the card to you. @ Attach this card to the back of the mailpiece, or on the front If space permits. 4. Article Addressed to: MONTICELLO PARTNERSHIP, LTD., A/K/A JEFFERSON NURSING CENTER ATTN: Administrator 1780 N, Jefferson Street Monticello, Florida 32344 MONTICELLO PARTNERSHIP, LTD., A/K/A JEFFERSON NURSING CENTER ATTN: Administrator 1780 N, Jefferson Street Monticello, Florida 32344 Postmark Hera Jooyco OA 4 ABS COMPLETE THIS SECTION ON DELIVERY A. Recaived by (Please Print Clearly) 8. Date of Delivery An3l-& DI Agent x O Addressee D. Is delivery address different from item 12 CI Yes If YES, enter dellvery address below: [1 No CG. Signature 3. Service Type Cartified Mail 1 Express Mall CD Registered ‘i Return Receipt for Merchandise C1 Insured Mail 01 G.0.D, 4, Restricted Delivery? (Extra Fee) OD Yes 2. Article Number (Copy from service label) PS Form 3811, July 1999 Domestic Return Recelpt 7003 1020 OO00 4?ib 1576 102595-00-M-0952

Docket for Case No: 06-001549